<form class="form-horizontal" role="form">
    
    <div class="form-group" style="height: 150px;   " >
        <img class="img-thumbnail" data-src="holder.js/140x140" alt="140x140" src="http://www.skydoor.net/Download?mode=photo&id=2899" style="width: 140px; height: 140px;"/>
    </div>
    
    <div class="form-group">
        <div style="color: #d9534f;"><h3><ins> Số địa chỉ</ins></h3></div>
    </div>
    <div class="form-group">
            <canvas id="myCanvas" width="700" height="200" style="border:1px solid #000000;"></canvas>
        </div>
    <div class="form-group">
        <div style="color: #d9534f;"><h3><ins> Phường xã</ins></h3></div>
    </div>
    <div class="form-group">
            <canvas id="myCanvas" width="700" height="200" style="border:1px solid #000000;"></canvas>
        </div>
    <div class="form-group">
        <div style="color: #d9534f;"><h3><ins> Quận/huyện</ins></h3></div>
    </div>
    <div class="form-group">
            <canvas id="myCanvas" width="700" height="200" style="border:1px solid #000000;"></canvas>
        </div>
    <div class="form-group">
        <div style="color: #d9534f;"><h3><ins> Tỉnh/Thành</ins></h3></div>
    </div>
    <div class="form-group">
            <canvas id="myCanvas" width="700" height="200" style="border:1px solid #000000;"></canvas>
        </div>
    
    </form>
</div>